The Change in DMFT of Six-Grade Primary School Children in Shiraz two Years after Implementation of the National Oral Health Reform Plan

Statement of the Problem: The oral health reform plan has been added to the Iran's health reform plan since the beginning of 2015. Evaluation of Iran’s oral health reform plan has rarely been conducted. Purpose: The aim of this study was to evaluate the change in DMFT among the six-grade primary school children of the city of Shiraz, two years after implementation of oral health reform plan. Materials and Method: A repeated cross-sectional study was conducted on six-grade primary school children of Shiraz in 2015 and 2017. About four hundred children were selected each year by cluster randomization sampling. The schools were randomly selected from three socioeconomically different types of schools including private schools, state schools in affluent areas, and state schools in deprived areas. The DMFT Index of selected children was compared between 2015 and 2017, and among three socioeconomically different areas. One-way ANOVA and Poisson regression tests were used for statistical analysis. Results: The mean DMFT of children was 1.47±1.83 in 2015 and 1.29±1.79 in 2017. There was significant difference in mean DMFT value between years 2015 and 2017 (p= 0.048). The percentage of children with untreated dental caries was 46% and 36.7% in 2015 and 2017 respectively. There was no statistically difference in DMFT of the three socioeconomically different schools. Conclusion: There has been significant improvement in DMFT of sixth grade school children of Shiraz two years after implementation of oral health reform plan.


Introduction
Iran's Health Reform Plan (IHRP) is a national program approved and started in May 2014 to improve accessibility and quality of state health services comprehensively [1]. It started with focus on general health promotion, prevention, and hygiene. Given the close relationship between oral health and general health and the impact of oral health on general health [2][3][4][5], the Oral Health Reform Plan (OHRP) was added to the IHRP at the beginning of 2015 [6]. OHRP intend to improve oral health by providing education, prevention, and treatment services to target groups. Children under 14 years of age, pregnant women, and lactating mothers were the main groups to receive packages of dental services.
Thousands of dentists, dental hygienists, and other trained auxiliaries were recruited to provide these services in two levels. Fluoride therapy, fissure sealant for first permanent molars, and restorative treatments for primary school children were part of these services and were provided free [7][8]. The first level was provided in "Health Houses" in rural areas and "Health Posts" in urban areas, and the next level services were provided in "Health Centers", all being part of Primary Health Care (PHC) Network [9].
Tooth decay is one of the most common oral diseases and has serious consequences for individuals and society, such as pain, dysfunction of the oral system and a decrease in the quality of life, the cost of treatment for the community and the loss of productivity of the individuals [10]. Studies conducted in different regions of Iran indicate a high prevalence of dental caries among young children and its significant differences among different regions of the country and between rural and urban areas [9][10][11]. The DMFT (decayed teeth, missing teeth due to caries, and filled teeth due to caries) Index of 12-year-old children was reported as 2.09 in 2012.
Scientific evidence shows that performing fluoride therapy and fissure sealant therapy are effective ways to prevent and stop dental caries [12][13][14]. These two services were highly appreciated by the OHRP authorities.
The main outcome of the OHRP was reported to be the reduction of dental caries among primary school chil- Regular assessment of the OHRP is essential for assessing its efficiency and effectiveness, and helps identify the strengths and weaknesses of this program. In addition, the evaluation of this program can provide valuable evidence for health-care providers to take measures such as the continuation of the program or making corrective changes in the program. In this regard, a oneyear evaluation of the fissure sealant program was conducted by the dental public health department of Shiraz Dental School in 2016 [16]. The success rate of fissure sealant in this one-year evaluation was low (only 47%) and many factors affected the quality of fissure sealants including the type of clinicians who applied the fissure sealant and the type of fissure sealant materials. The authors suggested the necessity of quality and quantity assessment of the program to achieve better results regarding the reduction of dental caries [16].
On the other hand, the increasing costs of health systems around the world have become one of the main concerns of managers and decision makers of health systems. The health system of Iran, like other countries, is faced with the challenge of rising costs. The implementation of the IHRP has led to an increase of about two times the tariffs for health care services, which put a large financial burden on health insurance organizations [17]. High cost is a major challenge to health promotion [18]. In OHRP, a large budget has been spent for infrastructure reconstruction of state dental centers, provision of equipment and dental materials, and the supply of human resources.

Discussion
The aim of this study was to conduct an evaluation of OHRP by assessing the probable changes in DMFT and The current study was conducted only in one city and in a short period (two years), using only one index (DMFT); however, considering the size of resources that OHRP has used, it is expected to observe more positive effects on Iranian's oral health. Regular and periodic assessments of OHRP, preferable multi-center studies, are recommended to evaluate the efficiency and effectiveness of the program.

Conclusion
The mean DMFT of six-grade primary school children of Shiraz has significantly decreased by 12%, two years after implementation of OHRP. This decline was more prominent in schoolchildren of deprived areas (23%).
Iran's oral health policy makers should promote regular multi-center assessment of OHRP outcomes in order to employ appropriate strategy.